Environmental and health hazards by massive earthquakes
Authors: Hasan Bayram, Tuba Rastgeldi Dogan, Ülkü Alver Şahin, Cezmi A. Akdis
Journal: Allergy (2023)

An earthquake with a magnitude of 7.8 Richter scale hit Southeastern Turkey and the Northwestern territories of Syria at 04:17 local time on 6 February 2023. The quake was followed by aftershocks with a 7.6 magnitude. The epicentre of both earthquakes was in Kahramanmaraş province, Türkiye, and more than 10,000 aftershocks were recorded (Figure 1).1, 2 These were the most powerful earthquakes in the region since 1939.2 The earthquakes have damaged an area of about 78,500 km2 including the cities of Hatay, Kahramanmaraş, Adıyaman, Gaziantep, Adana, Osmaniye, Kilis, Malatya, Şanlıurfa, Diyarbakır in Türkiye,3 and a large territory in provinces of Aleppo, Hama, Lattakia, Tartous and Idleb, Syria. Approximately 15 million people were living in these cities in Turkey and Syria at the time, with an additional 2 million Syrian refugees in the affected provinces in Turkey.2 As of 6 March, the earthquakes have caused more than 50,000 deaths and about 120,000 injuries across Türkiye and all areas of Syria.4, 5 In total, 448 healthcare providers, of which 101 were physicians, lost their lives.3 The widespread destruction of buildings and infrastructure including airports has affected about 18 million people and displaced more than 3 million in both Türkiye and Syria.4, 5 The heavy snow and rain in the region have exacerbated the situation and made it more difficult for survivors and displaced people living in tents. Disrupted communications and infrastructure hampered civil defence teams' ability to respond quickly and caused a delay in assistance from rescue teams from national and international partners.2 Local healthcare facilities are usually compromised following earthquakes because of the damaged health facilities and equipment, death or injury of staff, and loss of power and water supply.6 More than 15 major hospitals and more than 100 small health centres have suffered from partial or total damage. Those with collapse risk have been evacuated and patients transferred to facilities in other cities and field hospitals established for providing health care.2 Delivery of health care in such catastrophic situations is challenging and anticipation of the types of clinical and public health problems faced in disaster situations is crucial when preparing disaster responses. Massive earthquakes can have a devastating impact on human lives, infrastructure and the environment. Acute effects of earthquakes can occur during and immediately after the earthquake. Victims have been exposed to extremely high concentrations of dust and other particulate matter (PM) from collapsed buildings and other structures. PM larger than 10 μm can be inhaled to the lower airways through inhalation and mouth breathing that can occur under stressed conditions. Exposure to such high concentrations of particles may cause both acute and chronic respiratory problems such as pulmonary injury, bronchospasm, chronic cough, persistent bronchial hyperreactivity and declines in lung function.6 In some cases, gas from broken lines, carbon monoxide (CO) and smoke inhalation from closed areas and thermal injury to upper airways may occur due to exposure to fires from the earthquake site, and manifestations of an acute smoke inhalation injury may take several hours to develop.6 Although injuries are reported to be more common at the acute phase (7 days), pathologies including respiratory diseases may be more prevalent at subacute phases (8–30 days) of the earthquake.6, 7 Following the acute phase of the earthquake, the removal and transport of debris from buildings may spread dust that can reach high concentrations in the ambient air. The poor environment, with crowding, sleeping on the floor, cold temperatures, and unbalanced meals may exacerbate the diseases of the hurricane victims.8 Pneumonia, acute exacerbations of chronic obstructive pulmonary disease (COPD), asthma attacks and progression of lung cancer were the most common causes of hospital admissions for pulmonary disease during the 2011 Great East Japan Earthquake.9 Children, the elderly, and those with pre-existing respiratory and cardiovascular conditions are particularly susceptible to the health effects of these pollutants. These dust particles are also a health hazard to rescue workers; therefore, personal protection equipment, such as N95 respirator masks, should be used during rescue activities. Exposure to hazardous materials, such as asbestos, which is commonly used in many old buildings for insulation and other purposes, poses a risk for survivors and rescue workers. Asbestos particles released into the air during the abolishment of buildings and infrastructures can cause mesothelioma and pulmonary fibrosis. Silica particles can lead to silicosis and can also be released in high concentrations from the concrete and plaster coating walls and other surfaces. Rubble containing asbestos should be marked; its proper handling and disposal together with other hazardous materials is essential for the prevention of respiratory diseases. Most of the affected regions currently have a winter of continental climate between −5 and 15°C in the cities with snow and rainfalls. The injuries of the victims staying in the rubble until their rescues have been severely affected by weather conditions. Their injuries have been aggravated by cold weather leading to hypothermia, which was a serious risk factor for severity and survival in the current earthquake.2 In addition, transport and accommodation for the rescue and healthcare workers have been negatively impacted by the weather conditions. During the earthquake: Following the earthquake: Long-term effects: Communicable diseases, including respiratory and gastrointestinal infections, commonly emerge following disasters due to overcrowded temporary housing, population displacement, poor sanitation facilities and inadequate healthcare services in affected areas. Acute respiratory infections can be fatal among displaced populations in the first 3–5 days of the earthquake, and children and the elderly are particularly susceptible to these infections.6 Rescue and healthcare workers may also be at increased risk of respiratory infections. Earthquakes may also affect pre-existing respiratory diseases by disrupting their treatment, for example, by loss of power for those requiring oxygen or nebulisations, by destroying healthcare services and infrastructure, and by hampering access to hospitals and clinics. The risk of developing pulmonary tuberculosis (TB) can increase in displaced and overcrowded populations.6 Rescue and healthcare workers are highly vulnerable to infectious diseases due to the lack of water and hygiene. Continuous water and food sanitation and quality control are essential to prevent gastroenteritis and parasite infections. Post-traumatic stress disorder and depression are one of the most common complications of disasters such as earthquakes that can be seen within days of the acute event.6 The inhaled dust may cause acute attacks and exacerbation of cardiovascular problems, stroke, abortions and even premature death. In conclusion, powerful earthquakes can have significant impacts on public health, both during and after the recovery phase. After an earthquake, efforts are typically focused on repairing damaged infrastructure and restoring essential services. The long-term health effects of the earthquake on local populations should be considered, and all necessary steps to mitigate any potential negative impact should be implemented. It is important to monitor public health in the months and years following the event in the affected region and migrants away from the region. Additionally, it is important to take steps to restore the natural environment in the aftermath of an earthquake. Well-structured, well-organized, and well-prepared disaster measures, clarification of backup strategies, and challenges and lessons learned from previous events are critical for preparing for future disasters.6, 8 This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. C. A. Akdis has received research grants from the Swiss National Science Foundation, European Union (EU CURE, EU Syn-Air-G), Novartis Research Institutes, (Basel, Switzerland), Stanford University (Redwood City, Calif), Seed Health (Boston, USA) and SciBase (Stockholm, Sweden); is the Co-Chair for EAACI Guidelines on Environmental Science in Allergic diseases and Asthma; Chair of the EAACI Epithelial Cell Biology Working Group is on the Advisory Boards of Sanofi/Regeneron (Bern, Switzerland, New York, USA), Stanford University Sean Parker Asthma Allergy Center (CA, USA), Novartis (Basel, Switzerland), Glaxo Smith Kline (Zurich, Switzerland), Bristol-Myers Squibb (New York, USA), Seed Health (Boston, USA) and SciBase (Stockholm, Sweden); and is the Editor-in-Chief of Allergy. All other authors declare that they have no competing interests.